Based on interview and record review the facility failed to provide emergency services in accordance with acceptable standards of practice when there was no oxygen tank available in the Psychiatric Emergency Service (PES) crash cart during the code blue incident on 6/4/18. The deficient practice may have caused delay in provision of needed intervention and likely to adversely affect patient outcome. Findings: Review of Patient 1's "Code Blue Note" dated 6/4/18, indicated, "...Indication(s) for Code Blue Activation: Hypoxia (deprivation of oxygen)...Code Blue Outcome...Efforts terminated due to lack of sustained return of circulation..." Review of "Respiratory Care Services Respiratory Care Therapy Record" dated 6/4/18 at 6:55 AM, indicated, "Call to PES for code blue...started with ambu bag FiO2, 21. Unable to obtain O2 (oxygen) tank from crash cart..." According to https://medical-dictionary.thefreedictionary.com, FiO2 is the fractional concentration of inspired oxygen. The typical concentration of room air is 21%. During an interview, on 6/11/18, at 7:56 AM, Registered Nurse (RN) 1 acknowledged that there was no oxygen tank at the crash cart during the code blue on 6/4/18. RN 1 also stated that he did not check the crash cart before the start of his shift. Review of the facility policy titled, "Crash Cart Checks and Replacement", dated 3/17, indicated, "...Statement of Policy 1. The Registered Nurse or Licensed Personnel as designated by the unit/department is responsible for checking the unit/department crash cart to ensure...that emergency equipment is available and in usable condition...4. One standardized crash cart checklist form is furnished on each cart and will be used for both adult and pediatric crash carts (See Appendix B: Crash Cart Checklist)..." Review of "Appendix B...Crash Cart Checklist", dated 10/2017, indicated, "...Oxygen tank is present (and) full..."

Based on interview and record review, the Hospital failed to maintain an accurate central log for 22 of the 53 sampled patients seen in the main emergency department (ED) and for all of the pediatric patients seen in the 6M Pediatric Urgent Care. This was evidenced by: 1. Patient 15 was listed in the Main ED Log as disposition "Observation" [the Clinical Decision Unit located on the 4th Floor], even though Patient 15 was admitted to the hospital; 2. Patient 16 was listed in the Main ED Log as disposition "Left Without Being Seen" (LWBS) even though the Medical Screening Evaluator Nurse released him to the local police for transport to a Sobering Center; 3. The 6M Pediatric Urgent Care had no place in the printed log to indicate final dispositions. 4. Patient 1's final disposition was logged as LWBS even though he was removed from the ED by law enforcement. 5. Patients 2, 3, 4, 5, 7, 9, 10, 52, and 53 had incorrect final dispositions from the Main ED Log and Patients 52 and 53 had the incorrect final dispositions from the PES log. 6. Patients 24, 26, 27, and 28 had incorrect final dispositions from the Main ED Log; 7. Patients 36, 37, and 51 had incorrect final dispositions from the Main ED Log; and, 8. Patients 43, and 48 had incorrect final dispositions from the Main ED Log. Findings: 1. During record review on 4/8/15 at 11:20 AM, it was noted that the Main ED Log disposition stated "Observation" when Patient 15's ED clinical record stated that following a Medical Screening Examination (MSE) by the ED physician, Patient 15 was sent to the Clinical Decision Unit on 4th floor on 10/2/14 at 3:46 AM, and from there Patient 15 was admitted on [DATE] at 12:43 PM. During this record review, the Registered Nurse (RN 1) who was functioning as the computer driver for the electronic medical record (EMR) confirmed that the ED Log disposition of "Observation" was incorrect, and the correct disposition should have bee "admitted ." 2. During record review on 4/8/15 at 11:30 AM, it was noted that Patient 16 came to the ED on 10/7/14 and was assigned an ESI (Emergency Severity Index) score of Level 3. The ED Log had a final disposition of LWBS. The hospital's policy and procedure titled "Medical Screening - Emergency Department Medical Screening and Triage Guidelines" dated 7/13, stated "Individuals who are ESI Level 1, ESI Level 2, and ESI Level 3 will remain in the ED for physician evaluation, treatment, stabilization, and disposition." Review of the MSE nurse's Notes (RN 4) indicated that she did an MSE and then made arrangements for Patient 16 to go to a Sobering Center. Patient 16 agreed to this plan, and RN 4 released Patient 16 to the care of the local police to transport him to the Sobering Center. RN 1 confirmed that Patient 16 was an ESI Level 3 and should not have been released from the ED without being seen by the ED physician. RN 1 added that if RN 4 had changed Patient 16's ESI Level to a 4 or a 5, then RN 4 could have discharged him to the Sobering Center for follow up. RN 1 agreed that Patient 16 did not leave the ED LWBS, rather he was discharged by RN 4 to the Sobering Center. 3. Initial record review of the EMTALA log dated 11/28/14 to 11/30/14 from the 6M pediatric urgent care clinic showed there were no dispositions listed for any of the patients. Further record review revealed the same findings in the logs for 6 months since October 2014. During an interview on 4/09/15 at 11:30 AM, the Medical Director of 6M stated that the printed logs without the final dispositions have been a computer problem that the facility has been working on for 2 years. She performs weekly audits on the computer to ensure that the correct dispositions are entered. 4. On 11/03/14 at 3:27 AM, Patient-1 walked into the ED with a chief complaint of 10/10 right knee pain with an ESI 4. Medical record review showed that patient stated he had an appointment already at the outpatient clinic later that morning at 11 AM but still wanted to be evaluated by the ED physician for his right knee pain. After staying in the ED waiting area for approximately 30 minutes waiting his turn to see the physician, RN-9 requested the Deputy Sheriff to remove Patient-1 from the ED. The disposition on the medical record and the ED log was "LWBS". During an interview on 4/02/15 at 12:15 PM, the ED Director agreed the "LWBS" disposition was incorrect and that it should have been something else. 5a. On 11/20/14 at 9:32 AM, Patient-2 walked into the ED with a chief complaint of 8/10 right knee pain with an ESI 4. The RN MSE was done at 9:39 AM and at 9:40 AM was referred to the urgent care clinic. The disposition in the medical record and the ED log was "RN Referred to Urgent Care" which did not indicate whether the patient refused treatment, was refused treatment, transferred, stabilized and transferred, or discharged as a final disposition from the ED. 5b. On 11/30/2014 at 5:17 AM, Patient-3 walked into the ED with a chief complaint of 8/10 "left kidney pain" with an ESI 3. The RN MSE was done at 5:27 AM and at 8:04 AM was referred to the urgent care clinic. The disposition in the medical record and the ED log was "RN Referred to Urgent Care" which did not indicate whether the patient refused treatment, was refused treatment, transferred, stabilized and transferred, or discharged as a final disposition from the ED. 5c. On 11/30/14 at 10:07 AM, Patient-4 was an infant who was brought in by the parents for possible Tylenol ingestion with an ESI 3. The MSE was done by the ED physician at 10:44 AM and was subsequently sent to 6M which was the pediatric urgent care clinic for further follow up. The disposition in the medical record and the ED log was "RN Referred to Urgent Care" which did not indicate whether the patient refused treatment, was refused treatment, transferred, stabilized and transferred, or discharged as a final disposition from the ED. The medical record showed the ED MD stated "... discharge to pedi clinic to f/u level...". 5d. On 12/03/14 at 11:38 PM, Patient-5 walked into the ED with a chief complaint of 5/10 right side abdominal pain and was 21 weeks pregnant. The ESI was 3. The RN MSE was done at 11:43 PM and at 11:57 PM was referred to the urgent care clinic. The disposition in the medical record and the ED log was "RN Referred to Urgent Care" which did not indicate whether the patient refused treatment, was refused treatment, transferred, stabilized and transferred, or discharged as a final disposition from the ED. Since the patient was pregnant, she was actually brought to the OB L&D unit at 11:47 PM, not the urgent care clinic. On a different visit on 12/06/14 at 7:55 AM, Patient-5 walked into the ED with a chief complaint of leg swelling and right knee pain with an ESI 3. The RN MSE was done at 8:20 AM and at 8:22 AM was referred to the L&D unit. The disposition in the medical record and the ED log was "RN Referred to L&D" which did not indicate whether the patient refused treatment, was refused treatment, transferred, stabilized and transferred, or discharged as a final disposition from the ED. 5e. On 01/20/15 at 11:39 AM, Patient-7 walked into the ED with a chief complaint of 10/10 right upper tooth pain with an ESI 3. The RN MSE was done at 12:06 PM and at 12:10 PM was referred to the urgent care clinic. The disposition in the medical record and the ED log was "RN Referred to Urgent Care" which did not indicate whether the patient refused treatment, was refused treatment, transferred, stabilized and transferred, or discharged as a final disposition from the ED. 5f. On 10/01/14 at 1:26 AM, Patient-9 walked into the ED and stated, "My water broke". The patient was 38 weeks pregnant with 2/10 pain. The ED disposition was "RN Referred to L&D" which did not indicate whether the patient refused treatment, was refused treatment, transferred, stabilized and transferred, or discharged as a final disposition from the ED. 5g. On 4/06/15, the ED log showed Patient-10 had a chief complaint of "imminent delivery" and was referred by the RN to the L&D unit. The disposition in the medical record and the ED log was "RN Referred to L&D" which did not indicate whether the patient refused treatment, was refused treatment, transferred, stabilized and transferred, or discharged as a final disposition from the ED. 5h. On 01/18/15 at 1:27 AM, Patient-52 walked into the ED with a chief complaint stated by the patient as, " I have a feeling that I have pepper spray in my body. It's a hot sensation and it's eating me". The RN MSE was done at 1:35 AM and was referred to the PES. The disposition in the medical record and the ED log was "RN Referred to PES" which did not indicate whether the patient refused treatment, was refused treatment, transferred, stabilized and transferred, or discharged as a final disposition from the ED. The patient arrived in the PES at 1:45 AM and was triaged but was sent back to the ED at 2:24 AM. The disposition in the PES log showed, "SFGH Medical Emergency", which did not indicate whether the patient refused treatment, was refused treatment, transferred, stabilized and transferred, or discharged as a final disposition from the PES. 5i. On 01/14/15 at 8:41 AM, Patient-53 was brought by an ambulance to the ED with a chief complaint of erratic behavior. The RN MSE was done at 8:44 AM and was referred to the PES. The disposition in the medical record and the ED log was "RN Referred to PES" which did not indicate whether the patient refused treatment, was refused treatment, transferred, stabilized and transferred, or discharged as a final disposition from the ED. Patient-53 arrived in the PES at 8:51 AM and the RN MSE was done at 8:51 AM. The patient was sent back to the ED at 1:30 PM. The disposition in the PES log showed, "SFGH Medical Emergency", which did not indicate whether the patient refused treatment, was refused treatment, transferred, stabilized and transferred, or discharged as a final disposition from the PES. 6a. Record review of the Emergency Department (ED) Log, entry date 3/17/15, indicated Patient 24's final disposition was "RN Referred to PES (Psychiatric Emergency Services)". Record review of the Emergency Record for Patient 24, dated 3/17/15, indicated a triage time of 4:26 AM and the time moved to PES as 4:26 AM. In an interview on 4/8/15 at 11:18 AM, Registered Nurse 2 (RN 2) stated Patient 24 was discharged from the ED, and admitted to PES. In an interview on 4/9/15 at 2:15 PM, Nurse Manager P (NM P) stated Patient 24 was admitted to PES on 3/17/15 at 4:30 AM, and was discharged from PES to be admitted to unit 7B on 3/18/15 at 5:28 AM. 6b. Record review of the Emergency Department (ED) Log, entry date 2/22/15, indicated Patient 26's final disposition was to the Hospital's Observation Unit. In an interview on 4/8/15 at 11:18 AM, Registered Nurse 2 (RN 2) stated Patient 26 was placed on the Observation unit on 2/22/15 at 12:00 PM. RN 2 stated Patient 26 was discharged on [DATE] at 4:55 PM. 6c. In an interview on 4/8/15 at 12:02 PM, Registered Nurse 2 (RN 2) was asked the disposition (final placement or destination) of Patient 27's visit to the Emergency Department (ED). RN 2 stated Patient 27 was discharged to home from the ED. Record review of the Emergency Record for Patient 27, dated 2/18/15, indicated a disposition entered at 6:26 AM stating "Disposition- Patient: Disposition Type: Observation, Disposition: Clinical Decision Unit (CDU)- 4th Floor." A second line, entered at 11:32 AM, indicated "Patient left the department." Record review of the Emergency Department Log, entry date 2/18/15, indicated Patient 27's final disposition was to the Hospital's Observation Unit. In the same interview, RN 2 stated there were no notes from staff in the Observation Unit. RN 2 stated if Patient 27 went to the Observation Unit, it would be listed under the "Events- Transfer" section of Patient 27's Emergency Record. Record review of the Emergency Record for Patient 27, dated 2/18/15, indicated "Events- Transfer: Triage to Emergency Zone 4- Hall B. Emergency Zone 4- Hall. B to -2. Removed from Emergency Zone 4-2." In a concurrent interview on 4/8/15 at 12:07 PM, RN 2 was asked to explain the Transfer entries. RN 2 stated Patient 27 was triaged to Zone 4 in the Emergency Department. Patient 27 was moved from from Hall B in Zone 4 to bed 2, and discharged from Zone 4- bed 2. The Nursing Procedure: Discharge Note on Patient 27's Emergency Record, dated 2/18/15 and entered at 10:45 AM, indicated "Discharge: Patient discharged to home or self-care...". RN 2 acknowledged Patient 27's disposition was discharged to home and not the Observation Unit. In an interview on 4/8/15 at 12:10 PM, the Nurse Manager (NM) stated the physician in the morning may have been planning for Patient 27 to go to the CDU (Observation Unit). The NM acknowledged Patient 27 stayed in Zone 4, and was discharged from Zone 4. The NM stated the Patient Data screen had the capability to change the information to the correct disposition. 6d. Record review of the Emergency Department (ED) Log, entry date 2/14/15, indicated Patient 28's final disposition was "RN Referred to PES (Psychiatric Emergency Services)". Record review of the Emergency Record for Patient 28, dated 2/14/15, indicated a a triage time of 5:21 AM and the time moved to PES as 5:21 AM. In an interview on 4/8/15 at 11:18 AM, Registered Nurse 3 (RN 3) stated Patient 28 had a Medical Screening Exam (MSE) done by a registered nurse, and went straight to PES without being seen be a physician. In an interview on 4/9/15 at 2:30 PM, Nurse Manager P (NM P) stated Patient 28 was admitted to PES on 2/14/15 at 6:24 AM, and discharged from PES to be admitted to unit 7B on 2/14/15 at 5:09 PM. 7a. During record review and interview on 4/8/15 at 12:00 PM, RN 3 who was functioning as the computer driver for the electronic health record stated Patient 36 came in for possible sexual assault so the patient was sent to Pediatric Urgent Care right away after vital signs were taken. RN 3 verified the ED Log Disposition of Patient 36 was "RN Referred to Urgent Care." There was no indication on the ED Log if ED care was completed. 7b. During record review and interview on 4/8/15 at 12:22 PM, Patient 37 was brought in by ambulance after a fall. The record indicated Patient 37 was seen by the Triage Nurse at 7:51 AM. At 8:25 AM , Patient 37 was discharged from ED and was admitted to hospital ward. The ED log indicated the Disposition was "Observation." RN 3 who was functioning as the computer driver for the electronic health record verified the ED Log disposition of "Observation" was incorrect, and the correct disposition should have been "admitted ." 7c. During record review and interview on 4/8/15 at 12:30 PM, Patient 51 walked in to the ED on 1/2/15, and requested to be checked for hepatitis. The record indicated Patient 51 was seen by the Triage Nurse at 8:44 AM and was referred to Urgent Care at 8:45 AM. The ED log indicated the Disposition was "RN Referred to Urgent Care." RN 3 verified there was no indication on the ED Log if Patient 51 was treated at the Urgent Care and or his reason for walking in to ED was completed. 8a. During record review on 4/8/15 at 11:15 AM Emergency Department Log dated 2/16/15 indicated Patient 43's Disposition Type Observation Record review of Patient 43's chart indicated patient was admitted to triage area 2/16/15 at 1:42 AM with complaint of abscess to buttocks and a past medical history that included diabetes and hypertension. Record review of Patient 43's chart indicated Patient 43 was transferred to observation status at 7:29 AM " for the purpose of serial monitoring, testing, treatment and or evaluating the response to treatment of cellulitis " Record review entry at 2:09 PM indicated " Patient feeling better, will give vanco (vancomycin) at 14:00 and dc (discharge) home. " Record review Emergency Record Disposition indicated: Patient 43 transferred to Clinical Decision Unit (CDU)4th floor at 6:50 AM and discharged home at 5:28 PM. In an interview on 4/9/15 at 1:30 PM Nurse Manager (NMP) agreed there is no evidence in the Emergency Log that indicates Patient 43 was discharged from hospital. and review of log entries for the day do not include any further disposition for Patient 43. NMP said a column is needed on the ED log for disposition location in addition to disposition type currently on log. NMP sad the changes to the log are "in the works". 8b. Record review of Emergency Department Log for Patient 48 indicated patient was admitted on [DATE] at 1:04 AM with complaint of abdominal pain. Patient 48 was 24 weeks pregnant and stated " they ' re expecting me upstairs " . There is documentation that MSE was completed, there was no notation that patient was seen by a physician. Disposition Type was listed as "referred to L&D " . In an interview on 4/8/15 at 2:55 PM, RN 1 stated " they were expecting her in L&D so we sent her to the unit and she was not seen by a physician in the ED and disposition is indicated as Refer to L&D " . Review of 24 hour Triage (Outpatient) Census Sheet (Labor & Delivery) 3/21/15 indicated P 48 was seen by provider at 1:10 AM and discharged from triage at 10:30 AM to " Shelter " . There is no indication on ED log of final disposition. RN1 acknowledged that ED log did not reflect final disposition of Patient 48.

Based on interview and record review, the facility failed to demonstrate adequate MSE's by qualified RN's for 9 of 53 sampled patients (Patients 1, 3, 5, 16, 18, 20). The MSE is an ongoing process initiated in the facility's ED by the MSE qualified RN to determine if a medical emergency exists and to assign the patient to the appropriate ESI level. An inadequate MSE performed by the qualified RN may result in an ESI level that does not accurately reflect the immediate needs of the patient. Findings: 1. On 11/03/14 at 3:27 AM, Patient-1 walked into the ED with a chief complaint of 10/10 right knee pain. Pertaining to the chief complaint, the RN MSE by RN-10 showed the following : "Subjective: chronic right knee pain and has appt (appointment)today but wants to see ER MD for pain..., Objective: speaking in clear full sentences, ambulatory with steady gait with cane..., Pain: patient complains of pain described as, on a scale 0-10 rates pain as 10, Location right knee..., Medical History: Past medical history is not significant...". The RN assigned the patient an ESI of 4. During an interview on 4/10/15 at 9:46 AM, RN-8 who is an MSE qualified RN, reviewed the chart and stated she would have considered additional assessments that would indicate whether the right knee had swelling or redness and she would palpate the knee as well as compare the affected extremity with the left knee. She would also assess for numbness or tingling. Additionally, she would ask the patient if he took medications to alleviate the pain. The Nurse Manager who was present during the chart review acknowledged that additional information was also needed. Video record review on 4/02/15 at 10:38 AM showed the patient calmly stayed in the ED waiting area for approximately 30 minutes waiting his turn to see the physician when RN-9 requested the Deputy Sheriff to remove Patient-1 from the ED without consulting with the patient first. RN-10 documented on 11/03/14 at 4:24 AM, "Pt (patient)abusive to RN and reg (regular)staff. Verbal altercation w (with)IP (Institutional Police)results in arrest". The patient was removed from the ED without further evaluation from a physician. During an interview on 4/02/15 at 11:54 AM, the ED Director stated with patients with ESI levels of 4 or 5, the MSE qualified RN may refer patients to the outpatient clinics. The ED Director stated RN-9 and RN-10 should have reassessed and included the patient in the decision making process with the change of care and plan rather than deciding on their own to have the patient removed by the Deputy Sheriff. The facility's policy titled, "Medical Screening - Emergency Department Medical Screening and Triage Guidelines", date last reviewed 7/13, date last revised 10/09, defined ESI Level 4 and 5 as the following: "Individuals who are ESI Level 4 and 5 may have the following dispositions: i. After an MSE, the patient may be referred to a health clinic or urgent care center if an emergency medical condition does not exist, ii. Or the patient may remain in the ED for physical evaluation, treatment, and disposition...". 2. On 11/30/14 at 5:17 AM, Patient -3 had a chief complaint of 8/10 left kidney pain. Pertaining to the chief complaint, the RN MSE showed the following: "Subjective: Per pt(patient), she has had pain in her left kidney since last night. Woke up this AM and had burning during urination..., Objective: crying, cooperative, steady gait, MAE (moves all extremities), ABD (abdomen)non tender..., Pertinent negatives: trauma, hematuria, N/V (nausea/vomiting), ABD (abdominal)pain..., Pain: Patient complains of pain described as, burning, on a scale 0-10 patient rates pain as 8, Location L (left)flank lower back, pain is constant...". The RN assigned the patient an ESI level of 3. The medical record showed the RN referred the patient to the urgent care clinic at 8:04 AM and was not evaluated by the ED MD. The patient was not assigned an ESI level of 4 or 5 so referring the patient to the urgent care contradicts the referral policy since the patient had an ESI level of 3. The facility's policy, "Medical Screening - Department medical Screening and Triage Guidelines", date last reviewed 7/13, date last revised 10/09, defined ESI level 3 as follows: "...Triage- ESI Level 3 is a time order given to patients that may have an emergency medical condition that requires two or more resources in order for a patient disposition to be made. Resources may include hospital services, tests, procedures, consults, and interventions..., Individuals who are ESI Level 1, ESI Level 2, and ESI Level 3 will remain in the ED for physician evaluation, treatment, stabilization, and disposition...". During an interview on 4/10/15 at 10:00 AM, RN-8 who is an MSE qualified RN, reviewed the chart and stated she would have considered additional assessments such as a back exam, labs such as a urinalysis and pregnancy test. She would also have considered starting an IV. RN-8 agreed that the patient should not have been referred out with an ESI level of 3 and that it was not standardized procedure. The Nurse Manager who was present during the chart review acknowledged that additional information was also needed. 3. On 12/03/14 at 11:38 PM, Patient-5 walked into the ED with a chief complaint of 5/10 right side abdominal pain for one day and was 21 weeks pregnant. Pertaining to the chief complaint, the RN MSE showed the following: "Subjective: Right sided abdominal pain x1 day. 21 weeks pregnant..., Objective: alert, conscious, oriented x3. Skin pwd (pink, warm, dry). Ambulates with steady gait. Respirations even and unlabored, speaking in full and complete sentences..., Pain: No complaints of pain...". The RN assigned the patient an ESI level of 3 and was referred to the L&D. During an interview on 4/08/15 at 11:38 AM, the Nurse Manager reviewed the chart and stated he would expect the RN to clarify if there was a change in the pain status since the documentation showed "no complaints of pain" for this patient who had a presenting pain level of 5/10. During an interview on 4/10/15 at 10:16 AM, RN-8 who is an MSE qualified RN, reviewed the chart and stated she would have considered additional assessments regarding contractions and vaginal bleeding. The medical record showed Patient-5 returned to the ED on 12/06/14 at 7:55 AM with a chief complaint of bilateral leg swelling and 6/10 right knee pain for 13 days. Record review of the RN MSE did not show an objective assessment on the legs and knee. The patient was assigned an ESI level of 3 and was referred to the L&D unit. During an interview on 4/10/15 at 10:00 AM, RN-8 who is an MSE qualified RN, reviewed the chart and stated she would have assessed the patient's legs and knee for swelling, redness and range of motion. The Nurse Manager who was present during the chart review acknowledged that additional information was also needed. The facility's policy titled, "Emergency Medical Treatment and Active Labor Act (EMTALA)", administrative policy number 5.02, revised date 9/13, documented the following: "... A medical screening examination is the process required to reach, within reasonable confidence, whether an emergency medical condition does or does not exist. The scope and location of the examination must be tailored to the presenting complaint and medical history of the patient. The process may range from a simple examination (such as a brief history and/or physical) to a complex examination that may include laboratory tests...". The facility's policy titled, "Appendix B to 5.2 EMTALA, Medical Screening Examination" (undated), showed the following: "Protocol: Medical Screening Examination, A. Definition: This protocol covers the medical screening examination (MSE) performed in the Emergency Department (ED). The MSE is an examination performed by the physicians, or qualified registered Nurse, on all patients who present to the ED seeking care. The examination, viewed as an ongoing process, may range from a brief to a detailed examination involving all the laboratory, x-ray, and consultative resources available with SFGHMC's range of services, so that it is possible to reasonably determine whether an emergency medical condition exists or not, B. Data Base: 1. Subjective data: Statement of chief complaint, Patient history, and signs and symptoms relevant to disease process/injury and organ systems affected, Pain assessment to include and intensity (1-10 scale), Pertinent past medical history, medications, and allergies, Current immunization status for children and adults with surface trauma, Any treatments used to arrival, 2. Objective Data: Limited physical exam appropriate to disease process/injury, Level of consciousness (may use Glasgow Coma Scale), Vital signs, Skin signs, Emotional state, Physical appearance, size and location of injuries, with assessment of distal circulation, movement and sensation, as appropriate, Ability to ambulate and assessment of gait, as appropriate, Assessment of symptoms of pregnancy or possible labor, including term of gestation, as appropriate, Disease and age appropriate and radiological studies...". The medical screening class outline for the ED RN's dated 6/10 documented the following: "The triage nurse has the purpose to determine whether patients have an emergency medical condition, and if one exists to assign the patient to the appropriate triage category..., Perform the MSE by obtaining specific subjective and objective data from the patient or patient representative..., Objective data include a limited physical exam appropriate to the disease or injury...". 4. Patient 16 - During record review on 4/8/15 at 11:30 AM, it was noted that Patient 16 came to the ED on 10/7/14 and was assigned an ESI (Emergency Severity Index) score of Level 3. The hospital's policy and procedure titled "Medical Screening - Emergency Department Medical Screening and Triage Guidelines" dated 7/13, stated "Individuals who are ESI Level 1, ESI Level 2, and ESI Level 3 will remain in the ED for physician evaluation, treatment, stabilization, and disposition." Review of RN 4's notes indicated she had written "Medical screening exam completed" at 9:34 PM on 10/7/15. There were no notes written by the ED physician. Review of the MSE nurse's Notes (RN 4) indicated that after she did the MSE RN 4 made arrangements for Patient 16 to go to a Sobering Center. Patient 16 agreed to this plan, and RN 4 released Patient 16 to the care of the local police to transport him to the Sobering Center at 10:42 PM on 10/7/15.. On 4/8/15 at 11:40 AM, RN 1 confirmed that Patient 16 was an ESI Level 3 and should not have been released from the ED without being seen by the ED physician to complete the MSE. During a group interview on 4/9/15 at 2:20 PM, the ED Nurse Manager (NM) stated that it was a mistake to enter the statement "Medical screening exam completed" in any electronic medical record (EMR) where a physician had not seen ESI Level 1, 2 or 3 patients. The NM explained that the MSE was a process and until the ED physician examined patients with ESI Levels of 1, 2, and 3, and examined those patients with ESI Levels of 4 and 5 who chose to wait for the physician examination, then the MSE process was not completed. 5. Patient 18 - Record review indicated Patient 18 was admitted on [DATE] at 1:03 AM after a fall down five steps. Patient 18 was triaged as an ESI Level 3. The Registered Nurse (RN 5) charted "Medical Screening Exam Completed" at 1:05 AM on 10/11/14, even though the ED physician did not begin his examination of Patient 18 until 4:05 AM. On 4/8/15 at 11:50 AM, RN 1 confirmed that Patient 18 was an ESI Level 3 and needed to be seen by a physician before the MSE could be completed. 6. Patient 20 - Record review indicated Patient 20 was admitted on [DATE] at 6:17 AM for right leg pain. The Registered Nurse (RN 6) charted that Patient 20's "Medical Screening Exam completed" on 11/3/14 at 6:17 AM. The physician's notes indicated he began his MSE on 11/3/14 at 12:48 PM. On 4/8/15 at 12:00 PM, RN 1 confirmed that Patient 18 was an ESI Level 3 and needed to be seen by a physician before the MSE could be completed.

Based on interview and record review, the Hospital failed to provide completed written documentation that the risks of leaving against medical advice and benefits of receiving an examination or treatment were discussed for three of 53 sampled patients (Patients 21, 29, and 40) seen in the Emergency Department. This was evidenced by: 1. The Leaving Hospital Against Medical Advice form for Patient 21 was not completed, and the risks of leaving Against Medical Advice (AMA- when patients leave the hospital against the advice of their physician) was not documented in the Emergency Department (ED) Record; 2. The Leaving Hospital Against Medical Advice form for Patient 29 was incomplete; 3. The Leaving Hospital Against Medical Advice form for Patient 40 was not completed. Findings: 1. Record review of the Hospital's ED log, entry date 3/10/15, indicated Patient 21 left the ED AMA. In an interview on 4/8/15 at 10:40 AM, Registered Nurse 2 (RN 2) was asked to provide Patient 21's completed AMA form (a form signed by the patient and the physician stating vital health information was discussed, including the risks and consequences of leaving the hospital). RN 2 stated, "I don't see it in there." In a concurrent interview and record review on 4/8/15 at 2:50 PM, the Nurse Manager (NM) was asked to provide evidence that the risks of leaving AMA were discussed since an AMA form was not completed. NM reviewed Patient 21's ED record, dated 3/10/15, and referred to the Doctor Notes portions. It indicated "...but then left against medical advice w/o (without) signing paperwork. Pt (Patient) is aware of resources available to her and our willingness to treat her if she would like..." NM stated this statement was indicative that the risks were explained. No evidence, that a discussion regarding the risks of leaving AMA, was provided. Record review of the Hospital's AMA, AWOL & AWOL (At Risk) policy and procedure, revision date 1/2014, indicated "...Procedure. 1. Leaving Against Medical Advice (AMA)- A.1. ...the physician will explain the importance of completing the recommended course of treatment and the risks of not completing the treatment...B.3. Document the discussion with the patient in her or his medical record..." 2. Record review of the Hospital's Emergency Department (ED) log, entry date 2/13/15, indicated Patient 29 left the ED AMA. Record review of the Hospital's Leaving Hospital Against Medical Advice form for Patient 29, dated 2/13/15, indicated a portion stating "The Following Section Must Be Completed By The Physician". The Physician's Signature, Printed Name, and Community Health Network (CHN) Identification (ID) # sections were not completed. In an interview on 4/9/15 at 1:47 PM, the Nurse Manager (NM) acknowledged the incomplete sections, and stated "The physician didn't sign it." 3. Patient 40 was brought in to ED for medical clearance for jail on 2/6/15. Patient 40's diagnoses were poorly controlled diabetes (chronic condition associated with high sugar in the blood), chest pain and suicidal ideation. Review of the ED Log indicated Patient 40 left AMA (Against Medical Advice). During an interview and record review on 4/8/15 at 2:25 PM, the ED Nurse Manager stated Patient 40 left the ED once the patient was released from police custody. The ED Nurse Manager stated Patient 40 signed the Discharge Instructions form but did not sign the AMA form. The ED Nurse Manager verified on the medical record that there was no notes from the physician or the nurses if the AMA form was offered to Patient 40.

Based on interview and record review the Hospital failed to perform appropriate transfers for three of the 53 sampled patients when the Transfer Form for Patients 17, 18, and 46 were incomplete. Findings: 1. Record review indicated Patient 17 was admitted on [DATE] for treatment of a subacute stroke. He was seen by the Neurology Team and received an appropriate Medical Screening Examination (MSE) and stabilizing treatment. Since Patient 17 belonged to a different insurance group, his wife requested, in writing, a transfer to a hospital which accepted Patient 17's insurance. Record review indicated the Physician Certification was completely appropriately by the physician. The Method of Transfer was incomplete with missing data for the ambulance provider, the person accompanying the patient, the cardiac rhythm, the time of transfer, and an indication of whether the transfer request was sent with the patient. On 4/8/15 at 11:40 AM, RN 1 reviewed the record and confirmed that the transfer documentation was incomplete as stated. 2. Record review indicated Patient 18 was admitted on [DATE] following a fall of five steps. Patient 18 received the appropriate MSE and stabilizing treatment. Patient 18 belonged to a different insurance group, so she signed the Consent for Transfer to her covering hospital. The Physician Certification was completed appropriately by the ED physician but the Method of Transfer lacked the time of transfer and the RN's signature. On 4/8/15 at 11:50 AM, RN 1 reviewed the record and confirmed that the transfer documentation was incomplete as stated. 3. Record Review indicated Patient 46 was admitted to the triage area of the Main Emergency Department with a complaint of suprapubic pain. Patient 46 received the appropriate MSE and stabilizing treatment. Patient 46 belonged to a different insurance group so she was transferred to to her covering hospital. The Transfer Form indicated incomplete entries: Physician Certification time was blank, Ambulance Provider blank, and time of transfer blank. On 4/8/15 at 12:05 PM, RN 7 reviewed the record and confirmed that the transfer documentation was incomplete as stated.